Week 5: october 25-28, 1999

GOALS AND INSTRUCTIONAL OBJECTIVES
By the end of the week, the second quarter student will have an in-depthunderstanding of the diagnoses listed under Primary Diagnoses and SecondaryCommon Diagnoses.
The second quarter student will accurately perform an appropriate history andphysical exam on a patient or patient model presenting with one of thecardiovascular diagnoses listed under Primary Diagnoses, Secondary Diagnoses,and Tertiary Diagnoses when seen at the student’s clinical site or during apracticum exam.
The second quarter student will explain the pathophysiological changes that areassociated with the following conditions:
Premature ventricular contractions (PVC’s)
Myocardial infarction (MI) / Acute coronary syndrome
The student will also be able to describe how these changes may present in thepatient, the content of an appropriate history, the expected findings in a physicalexam, and an appropriate treatment plan or work-up.OBJECTIVES
The second quarter student will complete the following:
Accurately explain the epidemiology of primary and secondary commondiagnoses.
Name the (S) chief or common presenting complaint and relevantdescriptors of the primary, secondary common and uncommon and tertiarydiagnoses.
Accurately distinguish between (O) Objective negative and positive findingswhile performing a routine or specialty physical exam technique whenevaluating for, or in the presence of, the conditions listed for each primary,secondary common and uncommon, and tiertiary diagnosis.
Formulate a (A) Diagnosis and list relevant differential diagnoses frominformation gathered through history taking, physical exam, and diagnostictest results provided via case studies or reports or collected in the clinicalsetting.
Identify risks associated with specific missed diagnosis
Identify on written exam or in case presentation of a patient model or clinicpatient, a (P) Plan outlining the appropriate medication, non-medicinaltreatment, patient education and follow-up evaluation for primary andsecondary common diagnoses.(D) = definition onlyCARDIOVASCULAR: ANATOMY AND PHYSIOLOGY
The second quarter student will recognize and explain the anatomy, physiology,and common pathophysiology in sufficient depth for clinical application related tothe following Cardiovascular, Hematological, and Ophthalmological components. To meet this objective the student will utilize textbooks, models,electronic,computer or web-based programs, radiographic resources, and lecturesaccording to the standards identified in the Primary Care Associate Programrequired texts (see booklist in Student Manual).
The second quarter student will be responsible for basic anatomic knowledge of thecardiovascular system with emphasis on clinically relevant areas.
The second quarter student will utilize required texts and lecture material todevelop an understanding of the clinically important concepts of the following:
Chambers and vessels in the circulatory flow route, includingsystemic, pulmonary, and portal pathways.
The heart valves and their positions in systole and diastole.
Surface projections of the heart, position in the chest, and the fourauscultatory positions.
The coronary arteries: right coronary, left main and its two branches,the left anterior descending and circumflex; origin and generaldistribution.
Location and distribution of main arteries: aorta (thoracic andabdominal), carotids.
Location of important veins: inferior vena cava (IVC), external andinternal jugular.
State the origin and termination of the portal system, and why this issignificant in cardiac disease.
Conduction system: sinoatrial node (SA), arterioventricular node(AV), HIS bundle.
Nervous control of heart: sympathetic, vagus.
Basic cardiovascular physiology will be reviewed to the extent necessary tounderstand fundamental signs, symptoms, and diseases.
Intrinsic rhythmicity of conduction system, and delay points: reflectionon EKG.
Natural homeostatic feedback loops influencing heart rate; bloodpressure; (Starling's Law of the Heart).
Normal ranges of pulse and blood pressure through age groups andexertion.Primary Diagnoses:
The second quarter student will state the epidemiology, basicpathophysiology, etiological agents, and/or risk factors, preventive measures,signs and symptoms, differential diagnoses, investigative measures,management and patient education for the following diagnoses:
Health maintenance: CV promotion and screening
Secondary Diagnoses (Common):
The second quarter student will state the epidemiology, basicpathophysiology, etiological agents, and/or risk factors, preventive measures,
signs and symptoms, differential diagnoses, investigative measures, generalprinciples of management and patient education for the following diagnoses. Physician consultation is expected.
New onset premature atrial contractions (PAC’s)
Anticoagulant therapy in chronic atrial fibrillation (CAF)
Secondary Diagnoses (Uncommon):
The second quarter student will state the epidemiology, basicpathophysiology, signs and symptoms of the following diseases.
New onset premature ventricular contractions (PVC’s)
Tertiary Problems: Problems Requiring Emergency Management orHospitalization:
The second quarter student will be able to recognize these disorders andinitiate treatment. As well, they should be able to describe and identify thebasic pathophysiology, risk factors, preventive measures, patient educationand referral sources as appropriate:
Arrhythmias: PAT, uncompromised Atrial Fibrillation/Flutterwith a rapid ventricular rate; Ventricular Fibrillation,Ventricular Tachycardia
Elevated INR levels in the anticoagulated patient
CLINICAL PROBLEMS
For each problem the second quarter student will be able to perform a focusedhistory and physical, generate a differential diagnosis, and order appropriatediagnostic tests. They will be able to present the problem orally, do a write-up inSOAP format, and manage the diagnoses in Primary and Secondary CommonDiagnoses.
Increased bruising, bleeding gums, hematuria, hematochezia, melena
OBJECTIVE
In addition to the basic exam, the second quarter student will be able to perform thefollowing physical exam maneuvers:
Inspection - point of maximum impulse (PMI),
Palpation - for heaves, lift, PMI, tenderness, thrill,
To recognize S , S , gallops (S , S ), friction rubs, clicks
Correctly perform an electrocardiogram.Evaluation studies: State the indications for the following tests. Explain thesignificance of a normal vs abnormal result in relation to the diagnoses listed underPrimary, Secondary Common and Uncommon, and Tertiary Diagnoses, anddescribe the general cost effectiveness of the following tests:
Cardiac enzymes – CPK isoenzymes, SGOT, LDH (state which riseslate) Troponin T & I
Radiology•Other studies•
Rate, rhythm, P-wave, P-R interval, QRS complex
Normal sinus, sinus bradycardia and tachycardia.
Atrial and ventricular premature beats.
Ventricular fibrillation and tachycardia.
Holter monitor for evaluation of Arrhythmia, CAD
Cardiac catheterization for evaluation of CAD
Thallium scan for evaluation of Cardiac function
Treatment
The first quarter student will identify the indications, contraindications, side effectsand describe the general cost effectiveness of the following treatment plans:
Medications (In addition to the items listed below, read the appropriatesections in the Pharmacology Syllabus.)Medication
Thiazide Diuretics . CHF, High Blood Pressure
Triamterene / Spironolactone . CHF, High Blood Pressure
Nitroglycerine, Long Acting Nitrates . Angina, CHF
b-blockers . High Blood Pressure, Post-Myocardial Infarction
Coumadin . Chronic Atrial Fibrillation, prosthetic valve
Surgical interventions: State indications for:<
Coronary Artery Bypass Graft (CABG).
Percutaneous Transluminal Cardiac Angioplasty (PTCA).Patient Education: The second quarter student will be able to identify and thenexplain to patients the following topics:
Role of diet: prophylactic, hyperlipidemia, post MI
Side effects of drugs used for Cardiovascular Disease.January 3-7, 2005Cardiovascular IIREADING ASSIGNMENT
Please reference the previous listed diagnoses, clinical problems, exam skills,diagnostic tests, and treatments in the index of the following required texts:
BBZ 6th edDubin 6th edTierney 2004Hay 15th edWasson 5th edBurkeSchull or FischbachRothenbergMettler
There is a great deal of overlapping information about EKGs. Dubin isconsidered adequate and the programmed learning format is "user friendly".PHARMACOLOGY:note: bring to class Pharm Syllabus (CV), (Anticoagulants)
Pharmacotherapeutics for Advanced Practice